Questions and Answers:

Questions and Answers:


A mama on FB sent me a request to help her little one with his overall feeding concerns…my first request always is for the mama to send me a five day baseline diet.  This way I can see what he is eating and what he is not eating…also how well he did during each meal.  Karyn did a great job in sending me the baseline diet…and also listed her concerns…I was trying to attach the baseline diet here..but was not having any luck…Karyn…once this is on FB…can you resend the link…this way other mamas can see what a great job you did…and how all of the information you sent me really helps to make it easier for me to help you.  Thanks Karyn!!

 sal’s diet

After reading the menu and your concerns Karyn…I think it is important to determine at what level Sal is at with regard to his chewing abilities.  You did indicate in a response back to me that you believe he is able to chew at chewing hierarchy level number one…I am going to post below specifically what that means for you and for other mamas:


 Chewing Hierarchy Level Number 1 in children with Down Syndrome

Posted on April 16, 2012 by Kim

Once again my thanks goes out to the amazing Lori Overland and Sara Rosenfeld-Johnson for sharing their invaluable information.  As I have posted before I’ve taken many of Sara and Lori’s classes offered through  Not only am I thankful for the tremendous amount of information I have obtained…I am blessed to be able to work with the little ones I see for therapy…being able to implement what I have learned in order to help the children I see presenting with Down Syndrome…..and helping the mamas too of course! Below you will find information regarding Chewing Hierarchy Level 1.



“The goal of this hierarchy is to teach a graded, lateral chew with tongue-dissociation and movement across midline.  Use a thin bolus such as a veggie stick, thin pretzel or crunchy Cheeto.  Move to the next level in the hierarchy when the child can independently demonstrate the skill at the level you are working on with a stable jaw and dissociated tongue movement.”~Lori Overland, MS, CCC, SLP-Developing Oral-Motor and Feeding Skills in the Down Syndrome Population


Chewing Hierarchy Level 1 can only be addressed in feeding when the child has mastered this level in the pre-feeding exercises.  So…if your little one does not have a munch-chew….and you are only seeing a suckle (many children with Down Syndrome do not move past the suckle)… need to go back to pre-feeding Chewing Hierarchy Level 1.  This means instead of food you will be using various tools in order to facilitate the chew.  You can use the chewy tubes…offered at  The yellow ones are smaller and better for babies.  So it is important to remember….do NOT practice Chewing Hierarchy Level 1 during feeding if you do not see a munch-chew.  The goal of the chewing hierarchy is to teach all of the levels of chewing.  However, with little ones…babies that are learning to chew…the hierarchy MUST be presented as a pre-feeding exercise at first…and then foods are introduced. 

So….one last time…if your little one is still suckling and is not demonstrating the munch-chew….this is a pre-feeding Chewing Hierarchy level 1 exercise. 

Okay…so once you are seeing the munch-chew….present a stick shaped bolus…. like a pretzel stick or a veggie stick (I like the Snikkidy Cheese Fries Best-they give a lot of good sensory information) perpendicular to the lateral molar ridge…have the child take three bites…be sure to do this on both sides of the mouth.  That is the excersie…three bites on both sides of the mouth.  So: bite, bite, bite on the left….and bite, bite, bite on the right.   Question: How much food should go in the child’s mouth?- As much as they can handle…small bites for the little ones of course.

Why is this so important….because hierarchy level 1 is not only teaching chewing…it is motor planning for the following: tongue retraction and the lateral chew.  It is important to note right here…during your pre-feeding Chewing Hierarchy level 1…with the chewing tube…..once you see lingual retraction and the lateral chew on the chewy tube…and you see the munch-chew…NOT the suckle…you are ready to do Chewing Hierarchy level 1 with food. 

Since you will be doing Chewing Hierarchy level 1 during feeding….what will you be doing during the pre-feeding exercises with your little one…YES!….Chewing Hierarchy level 2.  My next post will be about chewing Hierarchy level 2…but wanted to end this post with the goals of level 2:  teaches the motor planning for tongue tip pointing and tongue retraction.

A few extra tips….when you are doing the pre-feeding Chewing Hierarchy Level 1……you can also use the Z-vibe with the green head (found on  and the Ark Probe also at talk tools.


 Okay…Karyn…if Sal is able to chew at this level…remember that during feeding this is how solid foods should be presented.  Do not have him eating the grilled cheese with his front teeth…you can present the food on his back molars…this will give him good input and also work on tongue retraction and the lateral chew.  See if he is willing to dip his grilled cheese into any sort of condiment…ketchup…ranch dressing….BBQ sauce (Sweet Baby Ray’s my fave!)…the heightened flavor of the condiments will give his sensory system more information which in return will help with chewing. 


Okay so if he is at chewing hierarchy level number one during feeding…during pre-feeding….with the chewy tubes you should be working on chewing hierarchy level number 2….see below:



Chewing Hierarchy Level 2 in children with Down Syndrome

Posted on May 3, 2012 by Kim

Many thanks again to Lori Overland and to Sara Rosenfeld-Johnson for offering the invaluable DVD trainings regarding feeding skills in children with Down Syndrome.  I especially send my thanks to Lori for answering many of my questions via email..thank you for your expertise and for always taking the time to answer my questions.  And remember has all of the materials, literature and tools needed to help you help your little one.   Today’s post is in reference to Chewing Hierarchy level 2.  Remember if your little one demonstrates the munch pattern while eating…then during the pre-feeding exercises you are working on Hierarchy level #2


Chewing Hierarchy Level # 2 as a pre-feeding exercise:

If you are working on Chewing Hierarchy Level #2 as a pre-feeding exercise…this means during regular feeding your little one is chewing food at Chewing hierarchy level #1…while she is eating at level #1…during pre-feeding you work on level #2…with toothettes presented to the lateral incisor and then to the back molar… or you can use chewy tubes….go to for tools and supplies for this level.  When using the toothettes…be sure to cut the wings off to make it easier to put inside your little one’s mouth.

So you want your little one to take two bites:

 One bite at the lateral incisor

 One  bite at the back molar

 What are we motor planning for?  Tongue tip pointing and tongue retraction.

Be sure to alternate sides…whatever you do on one side you do on the other side…unless you see asymmetry.

Once you see that your little one is capable of biting at the lateral incisor and then at the back molar ridge….you are ready to present this level during feeding.

And when you are working on chewing hierarchy level #2 during feeding…you are working on chewing hierarchy level #3 during pre-feeding.

Not only are you teaching your little one these chewing skills…you are also motor planning for the skills indicated above.



 Karyn….once Sal is successful with regard to level number 2 at the pre-feeding level…you should present his food using chewing level 2 as the model…hope that makes sense.  Biting on the side is very important for lingual retraction…tongue tip pointing, the lateral chew…and eventually the rotary chew.


This is a post I thought you would find helpful:

How to help your child eat better.

Posted on March 28, 2012 by Kim




That has now become my new phrase….I sort of coined it from Dr. Ross Greene’s phrase: Kids do well if they can….on a side note….Dr. Greene is incredible…and has much to offer parents of more challenging children with regard to behavior…..often described as “explosive“.

Dr. Greene’s first book titled: The Explosive Child is one worth reading….with lots of tips for parents of explosive children.  I have read all three of his books..if he has written more…I am just not aware……and I have also been to one of his conferences.  So if you need to….please do a Google search on him….he does have a website.  Anyway….back to the phrase I adopted from Ross Greene…..KIDS EAT WELL IF THEY CAN!  Parents……and teachers as well…..need to understand that when it comes to sensory feeding concerns with little ones…..and some big ones… eat what they are capable of eating…what their sensory neurons are capable of eating. 

So……to help kids get organized when it comes to eating….and to help them feel less pressure….and also to keep them part of the eating plan…I use the silicone cupcake mold sto help with overall feeding skills.  I call the mold: The Tasting Tray…..and the tasting tray is used during a feeding/therapy session….to help a little one try new foods and textures.  I put the various foods that we are working on in the tasting tray….keeping foods separated….each mold has a different food item… for this tray there would be six different options.  I can not speak specific as to what is in the tray….because it will depend upon the little one’s feeding/sensory concerns…and what we are working on…..the goal for the little one is to taste the items in the tray…..any food item that she does not want to taste….because her sensory neurons say NO….just by looking at the food….well that goes in the garbage pail:


I keep a plastic cup on the table…and any food item that the little one can not taste….well it goes in the garbage pail….I go by her lead…I want her to feel little to no pressure and stress when eating….but I also want her to feel encouraged to try new foods. 

Remember to have your speech and language feeding specialist help you and guide you with food suggestions that will expand your little one’s menu.  For me….and for the little ones that I have seen over the years…..hard crunchy foods offer good sensory information that help little ones try new foods, help with chewing, develop muscle memory and improve motor skills for chewing.  Foods that have heightened flavor with regard to sweetness, how salty the food is or how spicy a food is will also improve sensory skills.  Working on pre-chewing exercises will help to develop muscle memory….so that when your little one is ready to chew….she has the muscle memory skills.



I am working with a little one right now for feeding therapy…she has a very limited menu…only eating ONE food item.  We are expanding her repertoire and encouraging her to try new foods in her tasting tray…by encouraging her to taste the following items:

Veggie Stix

Magic Pops

Whole wheat toast…cut into strips

Veggie Chips

Dried strawberry….the hard crunchy kind….not the kind that is sort of sticky….as the little one I am seeing says: that’s too stickable for me to touch….what a great way to describe the food she can not eat

Chicken broth…cooled slightly….and then I put a small amount in the cupcake mold…and use a straw to drink.

Peanut butter.


Peanut butter is the only food item on this list that she likes….I encourage her to taste the other foods in her tray….if she likes…we keep in the tray…if not….we put in the garbage pail….

And by taste…for her this is tasting:

She puts food item on her lips….kisses the food with her lips…..sticks her tongue out and licks the food….puts food on her front teeth…puts in her mouth on the side touching the sides of her molars….putting in-between front teeth and side teeth……SHE HAS NOT BITTEN YET…..WHY….BECAUSE SHE EXPRESSED THAT SHE CAN NOT….BUT I AM SO PROUD…BECAUSE SHE HAS TRIED EVERYTHING IN HER TASTING TRAY!

If you need help coming up with a feeding plan for your little one…please send me your concerns…I am happy to help!

and yes of course….I purchased the tasting tray at 



Another helpful post:


Posted on December 29, 2011 by Kim



When it comes to feeding concerns in little ones……I definelty could spend a significant amount of time talking about eating and not eating in reference to toddlers and preschoolers.  This post is not only in reference to toddlers… is also in reference to eating and not eating in preschoolers. 

Doing many many feeding evaluations I spend a lot of time talking to parents, caregivers and teachers about overall feeding skills and abilities in little ones.  There are some children that have the ability to eat a variety of textures and foods.  This means that the structures and functions of their lips, mouth, tongue, cheeks, teeth, and throat are capable of biting, chewing and swallowing….they do not have an anatomical or physiological reason that would cause them to not eat.  However………the concern expressed by many parents (myself included in reference to my oldest when he was two and my Andrew now at ten)……the concern is…..WHY…..WHY do they refuse to eat certain foods????  Some kids can not even stand the sight of certain foods….the sight of the food may even make them gag…..sometimes it is the smell…..for me it is Beets…..I despise how they smell….and I gag a bit when I do smell them.  But for the little ones that have feeding aversions…it is to many many foods. 

In my experience there is a certain texture that is not tolerated by children with feeding aversions.  These are children that I would say have a hypersensitivity to certain textures.  Hyper-sensitivity means that they can not tolerate the texture…they are more sensitive to it-hypersensitive

Children with oral motor feeding-sensory concerns typically are NOT hyper-sensitive to soft pureed foods that do NOT require any chewing at all.  These foods are easily cleared from a spoon with the top lip….they do not need to be moved to the side by the tongue…they do not need to be chewed with the molars….you just swallow them.  These foods include: Stage 1 and Stage 2 (no chunks) baby food, yogurt (no pieces of fruit inside), ice-cream, pudding, shakes, smoothies, thin not too thick mashed potatoes-NO chunks………. and many other pureed foods that do not contain any chunks or smaller pieces of food.  This type of food is like a thickened liquid.  Children with sensory feeding issues….in my experience…..can tolerate this texture.  Please remember there are ALWAYS exceptions to the rule.  However, my experience has been that children with oral motor feeding issues-when it comes to a sensory difficulty….they CAN tolerate this pureed texture….remember this consistency DOES NOT have any pieces or chunks of a different texture in it… is completely pureed.

Children with sensory feeding issues usually CAN tolerate a hard crunchy food such as the following: cheese doodle, Gerber puff, Gerber wagon wheels, veggie sticks, pretzels, chips, french fries (but must be well done), chicken nuggets (only if well done…can not be mushy or cooked in the microwave), Oreos, graham crackers, hard crunchy cookies, pancakes cooked in toaster oven or toaster…not in microwave, same rule for waffles………basically all hard crunchy foods.  Now keep in mind…with this texture….they need to bite with their front teeth, lateralize to the side of mouth, chew with molars, then swallow.  Little ones with sensory issues CAN tolerate this texture…they are not getting negative sensory information.

Sooooo…..what CAN’T they tolerate?  They can not tolerate those in-between foods…the semi-solids….the foods that need your front teeth for biting (like a solid), the foods that need your molars for chewing (like a solid)…. they are not pureed and are not hard crunchy solids…they are the in-between…….the semi-solids….or as my oldest called them when he was three and could not tolerate…..they are the SWERBELIE foods.  These semi-solids require the biting and chewing like a solid….but do not have the hard crunchy consistency as a solid does….so when your little one is biting through this “swerbelie” food…her sensory neurons are receiving a lot of negative information….because it is the texture of the food that she can not tolerate…remember it is not an inability to bite or chew this food type….it is the actual texture of the food that she can not tolerate.  The in-between….semi-solid texture that gives their sensory neurons negative information.

And what are these foods: cheeses, deli meat, steak, chicken cutlet, pasta (unless cooked Al Dente….and that’s a maybe that your little one would eat the pasta if they have sensory issues…maybe they will eat it Al Dente), fruits, vegetables, eggs, oatmeal, cereal with milk (why because the milk made the cereal too mushy), soft pancakes, soft waffles, sandwiches, cold cuts…..and the list can really go on.

It is important to remember that we all eat because we need to and like to……we eat what we like.  Have you really ever made yourself something that you do not like to eat…and then forced yourself to eat it?  Probably no… why do that to your little one.  Forcing your little one to eat foods she can not tolerate due to sensory issues will make feeding a very negative experience.  She may start to refuse to sit in her high chair…or in her booster seat at the table…or where ever meal-time is for her.  Remember that when introducing new foods it is best to try at snack time when there is less pressure on your little one.  Make snack time in a different place from where she eats her three staple meals….try following this hierarchy when introducing new foods:


This means that you are asking your little one to first just look at the new food…..if she is willing ask her to smell it….then ask her to touch…and then if she CAN ask her to taste.  I have had little ones that remain in the LOOK stage for a few weeks before they are willing to SMELL the new food.

Also remember children with sensory feeding issues typically like foods with heightened flavor….foods that are saltier…sweetier even spicier….WHY….because their sensory neurons are hypo-sensitive….this means that they need more information when it comes to eating……….when trying a new food you may add a little more garlic powder or onion powder….some salt…. a little pepper.  Changing this one variable may help her to try the new softer food that she was not willing to try.  

Most importantly….and often times the hardest for parents…(and I know two of my four children have had sensory feeding issues…and Andrew still has)……remember to be PATIENT!  Do not pressure your little one….expand by offering new foods at snack time…let your little one know that she is working through the Look, Smell, Touch, Taste hierarchy so that she does not feel the stress to try new foods…we want her to want to eat….and to enjoy eating.

Make a menu of the new foods she has tried…..put them in categories…..list foods according to where she is in the hierarchy.  For example if she looked at and smelled the hamburger…put a picture of a hamburger on her menu and show a picture of eyes to represent that she looked at the new food….and a picture of a nose to show that she smelled the new food.

Try hard crunchy snacks such as dried fruits….veggie stix are great….dip them in various condiments…kids with sensory feeding issues typically like condiments…they are saltier…and increase flavor….try hard cheeses not soft cheeses.

Click on this link for more information regarding foods to choose and why: Feeding plan


I hope this post was helpful….I have more to add and will continue to post regarding feeding concerns.


Karyn: With regard to the following foods:



Fig Newtons

All should be presented at the chewing hierarchy level number one…this way you are working on the lateral chew and tongue retraction.  Does he like the Fig Newton?  That is a consistency I think he may not like..just because it does get a little mushy…and he may not like that texture.



 With regard to cup drinking:  read this post:

How to teach open cup drinking

Posted on April 7, 2012 by Kim



The three cups above are cut-out nosey cups….and are sold through talk tools and Amazon.  I wanted to post about them because they are great for addressing open cup drinking. 

The nosey-cups are ideal for people with limited range of motion of the head, neck or upper extremities, or arthritis. The Nosey Cup has a cut out for the nose that permits you to drink without bending your neck or tilting your head. Made from translucent plastic. Dishwasher safe.  Cut out for the nose permits drinking without bending neck or tilting head.  Nosey Cup Specifications:4 oz., 8 oz. and 12 oz. sizes.  Made from translucent plastic.  Dishwasher safe. 

What I like about the cups too…..I can assist with cup drinking and  I can squeeze the cup together as I am watching the little one with grading-knowing how much to open your mouth during eating or drinking…the child’s ability to know how much of a movement to make.




You indicate that he does not really like milk…he may need additional information…more flavor…you can add one of the yogurt drinks to his milk to give it more flavor….even cinnamon…a little nutmeg….also maybe add some fruit…a little ice..put in a blender….the cold and the additional sensory information may help him to drink the milk.  The goal is to give him additional sensory information..which will help both the sensory system and the motor system.



With regard to fork feeding:

Using a good grips cocktail fork is good for introducing fork feeding…and a perfect size…you want to use the fork upside-down and present perpendicular to the back molar ridge.   Spear a cheerio sized cube on the corner of the fork and place on the back molar.  This will work on grading of the fork..tongue retraction and chewing on the back molars.



Remember NOOOO!!!!! Sippy cups….only straw cups..using Sara Johnson’s straws are the best….use the honey bear if he has been resistant to the straws…I think you said that he is on the third straw.



Okay…this was a lot of information…tell me what you think…and follow-up with as many questions as you have!!!




About Kim

My name is Kim Marino and I have been practicing as a licensed speech and language pathologist since 1993. I work on Long Island providing diagnostic evaluations and services to children from birth to age 21. My experience is vast and am proud to say that I work with children that may present with articulation and phonological concerns, oral motor feeding concerns, Down Syndrome feeding, cognitive rehabilitation, auditory processing delays, receptive language delays, cleft palate feeding and sound development and expressive language delays. Most importantly, I am the mother of four amazing children and am happily married to my childhood sweetheart. I feel blessed to have my four children and so lucky to share this journey in life with my husband. I always had it somewhere in my head that I wanted to develop a blog or a website of some sort so that I could provide families with an additional that parents could help their little ones become a better communicator. And as I was developing this blog....I realized that I also needed to share the stories about my life and my children....and the funny things along the way that help to keep me smiling. Whether you are a working mother or not...finding balance between home, children and life can be a challenge....I hope that my blog helps to bring a smile to your face..and also some tools to help you help your little or big one. I hope you enjoy! Kim
This entry was posted in Questions and Answers. Bookmark the permalink.

4 Responses to Questions and Answers:

  1. Kim says:

    Hi Karyn…It is really important when he is biting food that he is biting on the side. Do not have him biting with his front teeth. Biting on the side will help with the lateral chew, lingual retraction, lingual lateralization and eventually the rotary chew. Depending on what level he is at with regard to the chewing hierarchy will depend on where you present the food. So if he is able to bite food three times on his back molars..chewing level one…then present the food on his back molars. If he is demonstrating competence at level 2, then you can present at the lateral incisor and then to the back molar.
    If he is suckling on the fig is especially important that the fig newton is presented on the molars.
    Post back with some more questions.

  2. Kim says:

    hi karyn…i was able to somehow figure it out….you should see it above now…i will post on FB too!! thanks again….and please post with more quetions. best,kim

    • Karyn says:

      Hi Kim,
      Thank you again for this information. Yes, it was a lot of information so I’ll continue to read it, comprehend it, and practice it with Salvatore.

      He happens to love fig newtons and appears to manage it pretty good. He started out sucking/munching it, but I think he has begun lateralizing it and chewing with his teeth more often. The pieces still need to be places toward the back on his molars.

      Regarding the grilled cheese sandwiches, I belive that he takes the bite with his front teeth and if the food doesn’t move far enough back to start chewing, he pushes it in his mouth with his fingers. I see the food moving from side to side, but it’s definitely a work in progress. He just started holding the grilled cheese on his own to take an appropriate size bite. Should I be focusing more on getting it to the side of his mouth as opposed to having him bite it? I think that’s what you mentioned above if I understood correctly.

      Again, thank you so much. I’ll be back with more questions.

      PS… Salvatore has a pretty wide range of foods that he eats but I think the food tray would still be beneficial for us in terms of behavior. We experience difficult behavior during feeding times occasionally. I thnk it boils down him not being about to express to us what he wants or what he doesn’t want at that point in time. I feel like if I give him leftovers or something similiar to the previous meal, he’s not interested. We’ll keep moving right along though. 🙂

  3. Karyn says:

    Hi Kim… Thank you for this wonderful information. I’m trying to post the rest of Salvatore’s food diet, but I don’t know how. Can you assist me?

Comments are closed.